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Standardizing Antimicrobial Prophylaxis in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation
Jordon C Mitzelfelt1, Roland C Hentz2, Elizabeth H Ristagno3
1From the Division of Pediatric Critical Care, Children's Mercy, Kansas City, Missouri.
Insights
Implementing a standardized narrow-spectra antimicrobial prophylaxis protocol for pediatric extracorporeal membrane oxygenation (ECMO) improved antimicrobial prescribing appropriateness. This change did not increase nosocomial infections in pediatric ECMO patients.
Area of Science:
- Pediatric critical care medicine
- Infectious disease management
- Extracorporeal membrane oxygenation (ECMO) support
Background:
- Antimicrobial prophylaxis guidelines for pediatric extracorporeal membrane oxygenation (ECMO) patients are not standardized internationally or nationally.
- Lack of clear guidelines leads to inconsistent antimicrobial use in this vulnerable population.
Purpose of the Study:
- To analyze the impact of implementing a narrow-spectra ECMO antimicrobial prophylaxis protocol.
- To standardize antimicrobial prescribing based on ECMO type and configuration.
- To compare antimicrobial use appropriateness and nosocomial infection rates before and after protocol implementation.
Main Methods:
- Retrospective, single-center study of pediatric patients (<18 years) requiring ECMO from May 2018 to December 2021.
- Inclusion of medical and cardiac surgical patients on various ECMO configurations (central/peripheral, veno-venous/veno-arterial).
- Comparison of antimicrobial prescribing appropriateness and nosocomial infection rates in pre-protocol versus post-protocol periods.
Main Results:
- Patients in the post-protocol period were 4 times more likely to receive appropriate antimicrobial prescribing (OR 4.4, P=0.036).
- Appropriate prescribing included both prophylactic and therapeutic antimicrobial use.
- No significant difference in the incidence of nosocomial infections (invasive or overall) was observed between the pre- and post-protocol groups.
Conclusions:
- A standardized, narrow-spectra ECMO antimicrobial prophylaxis protocol significantly increased appropriate antimicrobial prescribing.
- The protocol implementation successfully standardized antimicrobial use without increasing nosocomial infection rates.
- This approach offers a safe and effective strategy for antimicrobial stewardship in pediatric ECMO patients.
Background:
Prophylactic antimicrobials for pediatric patients requiring extracorporeal membrane oxygenation (ECMO) support are not well delineated; there are no consistent guidelines nationally or internationally. We analyzed antimicrobial use before and after implementing a narrow-spectra ECMO antimicrobial prophylaxis protocol intended to standardize prophylaxis by risk related to ECMO type and configuration.
Methods:
This retrospective, single-center study included children under 18 years old requiring ECMO between May 2018 and December 2021. Medical and cardiac surgical patients requiring open-chested (central) or peripheral veno-venous or veno-arterial ECMO were included. We evaluated the impact of an ECMO antimicrobial prophylaxis protocol by comparing the appropriateness of antimicrobial use as well as nosocomial infections in the pre versus post protocol.
Results:
Our study included 55 children with 58 individual ECMO episodes. More than 50% of the patients were open-chested during ECMO support, and the majority of ECMO support was veno-arterial. In the post protocol period, patients were 4 times as likely to have appropriate antimicrobial prescribing (Odds ratio 4.4; 95% confidence interval: 1.1-19; P = 0.036), including both prophylactic (per protocol) and therapeutic (chart documentation of an infection with appropriate therapeutic antimicrobials, including drug and duration). There was no difference in the odds of nosocomial infection occurring during ECMO pre protocol versus post protocol (pre vs. post protocol, P = 0.71 for invasive infections, P = 0.73 for all infections including potential colonization).
Conclusions:
After implementation of a standardized narrow-spectra ECMO antimicrobial prophylaxis protocol, we observed an increase in appropriate and standardized antimicrobial prescribing without concomitant increase in nosocomial infections.
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